“Cogent information about Ms Kerr’s declining mental health was provided repeatedly 2 to…”
Dated 18 Sep 2024, from the coroner for Surrey. Sent to 3 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedReplies were due by 13 Nov 2024.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
- Report dated18 Sep 2024
- Deadline13 Nov 2024
- Published on judiciary.uk18 Sep 2024
- Today27 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Surrey County Council | Response publishedPublished on judiciary.uk in September 2024. |
| Surrey Police | Response publishedPublished on judiciary.uk in September 2024. |
| Surrey and Borders Partnership NHS Foundation TrustNamed in the report as “Surrey and Borders Partnership” | Response publishedPublished on judiciary.uk in September 2024. |
The coroner’s concerns
– (1) Cogent information about Ms Kerr’s declining mental health was provided repeatedly 2 to Surrey and Borders Partnership secondary mental health teams from the refuge support workers. It was not explored with them, and insufficient weight was given to it during the triage process. Ms Kerr was not provided with appropriate and timely referrals for mental health treatment. Despite the evidence that significant changes are being put in place the efficacy of these changes has not yet been evidenced. (2) Ms Kerr was seen at the police station and hospital in an extremely psychotic and paranoid state. Police records showed that she had been arrested and charged with carrying a bladed article. It was also recorded that she had subsequently carried a nail file, for her own protection. The officer who saw Ms Kerr on the 31st March 2023 was unable to read the records because Ms Kerr’s condition meant that the officer could not leave the interview room before Ms Kerr decided to leave the station. The risk this posed to the public was therefore not considered. No action was subsequently taken in relation to the risk. (3) The SCARF process does not enable information sharing between the Police, Mental Health Agencies and Surrey Adult Safeguarding out of hours. It is under review. It remains unclear how information sharing out of hours is to be achieved in a timely fashion to safeguard individuals and the public. (4) The refuge was not made aware of Ms Kerr’s presentation on the 31 st March 2023 by Surrey Police. Her delusions about the actions of refuge workers could have put them in danger.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2024-0498
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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